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    Acute Venous Thromboembolic Disease (beta)

    Official guideline from the American College of Emergency Physicians.

    Summary by Eric Steinberg, DO
    Strength
    Level A
    Level B
    Level C

    Recommendations

    Risk Stratification
    1. For patients who are at low risk for acute pulmonary embolism (PE), use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.
    2. In patients older than 50 years deemed to be low or intermediate risk for acute pulmonary embolism (PE), clinicians may use a negative age-adjusted D-dimer* result to exclude the diagnosis of pulmonary embolism. *For highly sensitive D-dimer assays using fibrin equivalent units (FEU) use a cutoff of age×10 μg/L; for highly sensitive D-dimer assays using D-dimer units (DDU), use a cutoff of age×5 μg/L.
    3. Selected patients with acute pulmonary embolism (PE) who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the emergency department (ED) on anticoagulation, with close outpatient follow-up.
    Intervention
    1. Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental pulmonary embolism (PE) without associated deep venous thrombosis (DVT) should be guided by individual patient risk profiles and preferences. [Consensus recommendation]
    2. In selected patients diagnosed with acute deep venous thrombosis (DVT) , a non-vitamin K antagonist oral anticoagulant (NOAC) may be used as a safe and effective treatment alternative to low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA).
    3. Selected patients with acute deep venous thrombosis (DVT) may be safely treated with a non-vitamin K antagonist oral anticoagulant (NOAC) and directly discharged from the emergency department (ED).
    What do the icons mean?  
    Research PaperWolf SJ, Hahn SA, Nentwich LM, et al. American College of Emergency Physicians. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med. 2018;71(5):e59-e109.